A 44-year-old man comes to the office for follow-up after a recent hospitalization. The patient went to the emergency department with palpitations 2 weeks ago and was found to have atrial fibrillation with rapid ventricular response. He was admitted to the hospital, where he spontaneously converted to normal sinus rhythm overnight and was discharged home the next day. Prior to this episode, the patient had gone on an alcohol drinking binge during a friend's bachelor party. He otherwise rarely drinks alcohol. Medical history is unremarkable. He is a lifetime nonsmoker. Blood pressure is 124/70 mm Hg and pulse is 78/min and regular. Estimated jugular venous pressure is normal. Examination shows no abnormalities. Review of laboratory results from the hospital admission shows normal creatinine level, liver function tests, thyroid studies, and lipid panel. Echocardiogram shows normal left and right ventricular function and no valvular abnormalities. Which of the following is the best next step in managing this patient?

Question

A 44-year-old man comes to the office for follow-up after a recent hospitalization.  The patient went to the emergency department with palpitations 2 weeks ago and was found to have atrial fibrillation with rapid ventricular response.  He was admitted to the hospital, where he spontaneously converted to normal sinus rhythm overnight and was discharged home the next day.  Prior to this episode, the patient had gone on an alcohol drinking binge during a friend's bachelor party.  He otherwise rarely drinks alcohol.  Medical history is unremarkable.  He is a lifetime nonsmoker.  Blood pressure is 124/70 mm Hg and pulse is 78/min and regular.  Estimated jugular venous pressure is normal.  Examination shows no abnormalities.  Review of laboratory results from the hospital admission shows normal creatinine level, liver function tests, thyroid studies, and lipid panel.  Echocardiogram shows normal left and right ventricular function and no valvular abnormalities.  Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec25c8_d09e_8827_bc81_75a3dee40a83_MD0003_00 This patient had an episode of atrial fibrillation (AF) that spontaneously resolved within 24 hours. The pathophysiology of AF involves aging and comorbidities (eg, hypertension, heart failure) that cause atrial remodeling and create an underlying substrate for AF to develop. The substrate creates a lower threshold for triggers (eg, binge alcohol intake, hyperthyroidism) to initiate and sustain AF; however, sometimes triggers can cause AF in the absence of underlying substrate. After a first episode of AF, patients with risk factors for underlying substrate typically develop recurrent (ie, paroxysmal) or permanent AF. underlying substrate In contrast, patients without risk factors for underlying substrate (eg, age <50, no significant medical history) are relatively unlikely to experience recurrent AF, especially when the trigger of the episode is removed (eg, cessation of binge alcohol intake, treatment of hyperthyroidism). This is at least part of the reason these patients have low thromboembolic risk associated with AF. They often have a CHA₂DS₂-Vasc score of 0 (as in this patient), for which chronic anticoagulation is not indicated. Patients with a CHA₂DS₂-Vasc score of 1 also have relatively low thromboembolic risk and often do not require chronic anticoagulation. In patients with a CHA₂DS₂-Vasc score ≥2, chronic anticoagulation is indicated and is accomplished via the administration of a direct oral anticoagulant (eg, rivaroxaban, apixaban, dabigatran) or, less commonly, warfarin (Choices D and E). (Choice A) Amiodarone is used occasionally for maintenance of sinus rhythm in patients with recurrent, symptomatic episodes of AF (ie, rhythm-control strategy). This patient has spontaneously converted to sinus rhythm, and amiodarone is not indicated. First-line rate control agents (eg, metoprolol) are commonly used but are not needed in patients with relatively low likelihood of recurrent AF. (Choice B) Dual antiplatelet therapy with aspirin and clopidogrel has shown some benefit in lowering the thromboembolic risk in patients with AF. However, the therapy is rarely used as anticoagulant agents (eg, rivaroxaban, warfarin) provide greater benefit with roughly the same level of increase in bleeding risk. Educational objective: Patients without underlying risk factors who develop atrial fibrillation typically have low associated thromboembolic risk. Those with a CHA₂DS₂-Vasc score of 0 have very low thromboembolic risk, and chronic anticoagulation (eg, rivaroxaban) is not indicated. In addition, patients with a CHA₂DS₂-Vasc score of 1 have low thromboembolic risk, and chronic anticoagulation is often not required. References: 2014 AHA/ACC/HRS Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. (http://www.ncbi.nlm.nih.gov/pubmed/24682347)

A 44-Year-Old Man Comes to the Office for Follow-Up After